HomeMy WebLinkAboutT15N R1W SEC 30 SW4NE4NW4SW4 ' MUNICIPALITY OF ANCHORAGE '
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
525 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
LEGAL D ESCRI~T~ON
s Vq,./VZ
LOCATION
PHONE
C]UPGRADE
DISTANCE TO: I W~ell
Manufacturer ~Z~il~ob,¢t¢t~' 7"~1/1
Lq capacty nga ohs ~
/~ / IF HOMEMADE:
Manufacturer
DISTANCETO: Iwell / Z 7 '
No. of lines Length of each line
Length Width
Type of crib Crib diameter
DISTANCE TO: Building foundation
DISTANCE TO: Well
Class Depth. .
Absorption area ·
II,side length
welling
Foundation .~ ,.~ !
[D,,,e,,ing 6"q"'
IWidth
Material
Nearest lot line ~!
Total length of line;~ Trench width
ben~"~ileeamt ~'~ ~-p inches
Material
7 ~er :~E=
Depth
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMITN~ /7/.~ '7~
Total effective absorption area
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot llne PERMIT NO,
Sewer line Septic tank Absorption area(s}
OTHER
PIPE MATERIALS
ASTH
SOIL TEST RATING
t25- .-~T 8R :: ~ :~"~ .
INSTALLER
REMARKS
MUNIC~PALiT/ OF '"~0~
APPROVED
DATE
72-013 (Rev. 3/78)
LEGAL
DEPARTMEN]' OF WEALTH AND ENVIRONMENTAL PROTECTION
825 L ST'REET~ ANCHORAGE, AK 99501
264-4720
PERMIT NO:
[)ATE ISSUED:
in" ~
84 ) 7.:::8
08/.27/84
APPL I CANT:
ADDRESS:
· CGNTA[]T F'HONE:
STONE'S EXCAVATING
P 0 BOX 773272
EAGLE RIVER~, AK 99577
6G8-2915
L..EGAL DESCRIP:
..OT SIZE:
._eT ~_OCAT ION:
MAX BEBROONS:
SUBDIVISION: NA LOT: NA
SECTION: 30' TOWNSNIP: 15N RANGE: iW
~.5A (GQ.FT. OR ACRES)
SW1/4~ NE1/4, NW1/4~ SW1/4
4
BLOCK: NA
Listed below are
system. Choose the opt ion
the optioes available t.o you in de'signing your sep'Lic that best Fits your site.
DEPTN TO PIPE BOTTOM (FT.) 4.0 4.0 4.0
GRAVEL DEPTH (FT.) 7.0 0.5 3 5
TOTAL. DEPTH (FT.) 11.0 4.5 7.5
GRAVEL WIDTH (FT.) ;~.5 20.0 5.0
GRAVEL LENGTH (FT.) 36.0 38.0 54.0
GRAVEL VOLUME (CU.YDS.) ~).5.0 28.2 40.0
TANK SIZE (GALS) 1,250.0 ** 1,250.0 ** 1,~50.0 **
SOIL RATING (SQ.FT. /BR) 1~5 1~5 1~5
TANK NUST HAVE qT LEAST TWO COMPARTMENTS
I certify that:
I am Familiar with the requirements For' on-site sewers and wells as eet
Forth by the ~unicipality oF Anchorage (MOA) and the State oF Alaska.
~. I wi].], install the system in accordance with all MOA codes aed regulatiens~
and in compliance with the design criteria oF this permit.
3.' I will adhere 'Lo all ~1OA and S'La{e oF A~laska ~equirements For the set back
distances From any e:.,'isting 'well, wastewater disposal system or' public
sewerage system on this or any adjac, ent or 'nearby lot.
4. I understand that this permit is valid For a maximum o£ '4 bedrooms ~nd
any enlargement will' requir-e an additional~.permit~
IF A LIFT ~,TATION IS INS]~ALLED IN AN AREA COVERED BY MOA BUILDING C.JDES~
' TI~IEN (1) AN ~- , '~ c,' ,
E_E~]R]4~AL PERMIT AND INSPECTION MU~F BE OBTAINED; (~) AS-BUIL]'S
WILL. NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
EI..LCFRICAL .WORI.~ ,ttJ~F BE DONE BY A~.ICE,'4~D ELECTRICIAN.
APPLICANT: STONE'S EXCAVATING ~ ~
D/--
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, A{aska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR=
LEGAL DESCR,PT,ON= 5 lO///+, N ~' V~., N ~u 'h,b 5 ~ Y:~,
SLOPE
1
2
3
4
5
6
7
8
9
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
10
11
12
13
14
15
16
17
18
19
IF YES, AT WHAT
DEPTH? ~./A
Reading Date
Gross Net
Time Time
20
PERCOLATION RATE (minutes/inch)
TEST RUN SETWEEN FT AND -- FT
PERFORMED~Y: JO~-~ ~, ~ CERTIFIED BY:
72-008 (6/79)
W LLS
LASKA 99567 o TELEPHONE 688-2759
)WNER OF LAND ~ ~f__ ~,~,~_¢d1.O,3~O_ DEPTH OF WELL.
,DDRESS _.~-_3~t t,~,: ,-.~ ~,,.,? .,~O.,:~t ~,__ ,. ).~ O/ STATICLEVELOFWATERFT.
~EGAL DESCRI~ION ~)~c,Ad:.? ~.~ td,~, ~- ,J.,,o~ ~/~ /Z~-' DRAW DOWN ~.
'E~IT NUMBER - KIND OF CASING
¢IND OF FORMATION:
:rom.{ .... Ft. to ~ F~, ~/{i~:" ~/~;~' ' . From _Ft. to_ Ft._
'~ ...... ..... '~'~' DEPT~.OF HEAUH &
-rom "~'~ Ft, to L~-.> _Ft. t~;)~ · ~4~?~-~ .. From _ _Ft. to
~rom Ft. to FL ~4)'J~t ~ O~ ~ ~ From_ Ft. to Ft
. L~.~/ ~, ,~ 7~* ~* ' ~,~c~;--x /~ ' O~ ~'~/<' From Ft to
?rom ' Ft. to Ft. 0~/' ~//~¢i~.~ ¢-~
Ft.
Ft.~
?rom Ft. to Ft. -~) <~ ?~d~ _ From_ Ft. to_ Ft.
'"~'.,~',77~ . ' . : . . . . ,.
' '5~¢~',~~ Ft to '~L~ Ft ~:~. ~ -..(~t?.~ ,f~'-~-,d'~From _~Ft. to '
'.~;~iL~¢ ~- ' Ft :¢4~?' ' ~(~' ~q~ /.~)~.~ From Ft. to Ft.
~ron - . Ft. to ~, /~ Ft. ~,.~: .... '~
'rom _Ft. to Ft. '~ ':' ~ 3 Z~ ~* ~>~/.~ e ! C From~ Ft. to .... Ft.
'rom_ Ft. to~ Ft. ,~d'~/xt3 C)~.,Oq, (~rT~ ' From Ft. to Ft.~
, ,~,~d ~,, o~ ...... ~ ge From Ft. to Ft.
~rom ~ Ft. to
~rom_ ' Ft, to__ Ft.~ ~ From _Ft. zo Ft.
/IISCL. INFORMATION:
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343;4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
SW¼; NE¼; NW¼;SW¼; Sec 30; T15N; R1W
Location (site address or direbtions)
Property owner
Mailing address
Lending agency
Mailing address
Agent Clnd¥ Wilson
Address
18741 Monastery Drive
Key Bank of Washinqton Day phone
P.O. Box 11500 Tacoma, Washington
Day phone
Partner's Realty
Day phone. 694-4994
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 ~
3. TYPE OF WATER SUPPLY:
Individual well xXX
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADE{
lng to the legality and status of system.
attest-
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
72-025 (Rev. 1/91) Front MOA #21
Individual on-site X×X
Community on-site
pUblic sewer
If community wastewater system, provide written confirmation fr State
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is incompliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S
17034 Ea~le River Loop Eoacl No. 204
Address Eaale Riw~.
Engineer's signature
DHHS SIGNATURE
~" Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage /~,~.~\
DEPARTMEN OF HEA' -H & HUMAN SERWC CE IV E D
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)[~;~8-~7~99?
Health Authority Approval ~'"""~'"~* Municipality of Anchorage
""" '=~'~"~'ept. Health & Human Services
Legal Description: ~,b~t14.' J il,4: Sw I[+ 5¢(,, ~ Parcel I.D.: O ~1 -- ~o ~ - ) ~
A. WELL DATA ~SN2 R}~] ~,H,
Well type '~1
Log present {~'N)
Total depth
Sanitary'seal,q)
Date of test
Static water level
Well production
FROM WELL LOG
If A, B, or C. attach ADEC letter. ADEC Water system number
Cassd to /~ t'~--# ~ Caa!ng hsight (abovs ground) Wires properly protected (~)
AT INSPECTION
g.p.m. . ~J~ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0
Nitrate O. ~ Other bacteria
IL
Date of sample: ,Z-J/~/~I:~ Collected by:
S & S ENGINEERING
]7034 Eagle River Loop Road NO. 204
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Date installed ~-~'"'~' Tanksize ~ Number of Compartments ~ Cleanoutsi~N)~-'~
Depression (Y(~ /'J~ High water alarm (Y~ /t//~,
Pumper
Foundation cleanout (Y,~
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Soil rating (g.p.d./fF or ~) 12.5' System type -T'l~.E_~(,
Length '~-~,~ ' Width ~O" Gravel thickness below pipe ~ Total depth
Effective absorption area 5~ ~¢Monitoring Tube present'N) ~ Depression over field
Fluid depth in absorption field before test (in.); ~ Immediately after--gal, water added (in.):
Fluid depth ~/' (ins) Minutes later: ~ ~J~ Absorption rate = (~ ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~?~ ~ If yes, give date ~
72-026 (Rev. 3/96)*
LIFT STATION
Septic/holding tank on lot
Absorption fidd on lot
Public sewer main
Sewer/septic service line
Manhole/Access (Y/N) ~
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
lbo ~+
Size in gallons
"Pump on" level at*
"Pump off" level at*
]~-
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout IC/O ~-~'
Lift station 1(20
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 10I'~ Properly line )O'~' Absorption field ~¢¢.~
Water main/service line io'4' Surface water/drainage iCO'4' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Properly line I b ~ 4- · ~,
· Building foundation lO Water main/service line
Surface water JoO t J- , Dilveway, parking/~,ehicle storage area
Curtain drain f, Jc~4~;; K 14o~-f Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections a
in conformance with MO,~ HAA_rluidelings in effect on this date.
Signature ___ ,~/~
Engineer's Name ~',~ ~/~ '~/~ ~-- ~
Date t}~/r7 [R 7
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL NO.~. ~
During a recent Health Authority Apu~oval on-site inspection
,and test of the potable water supply well on
of ~l~ ~ ~,x~-~O Subdivision, the well's
productivity was determined to be~..~ gallons per minute.
The minimum well productivity req6ired by this Department
(AMC 15.55) for a ~ bedroom, residence' is 0,~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all co~ies of the subject
Health Authority Approval.
DEC--I6-9? TUE 12:14 C.ROLF.~IILTON. 1 888 898 ?655 P.02
N8~%cg'3~'~V 330 ·
BUILT
WATER WELL ADVISORY.
HEALTH AUTHORITY APPROVAL NO. /~/~
During a recent Health Authority Approval on-site inspection and
test o[ th~ pota_~ble water supply well on Lot __ Block .__
of ~V~ ~c~ -~' ~/~-~/~ Subdivision, the well's productivity
was determined to be~o'~ gallons per minute. The minimum well
productivity required by this department (AMC 15.55) for
a //- bedroom residence is ~.~Z gallons per minute.
Although the subject well currently exceeds this minimum
requirement, all parties concerned are advised that the
production cspacity of the well may fluctuate. Restriction of
noncritical water uses such as washing cars and watering lawns
and gardens may be required.
This advisory must be attached to all copies of the subject
Health Authority Approval. ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
.~1'~,~ - t,O~ HAA#
1. GENERAL INFORMATION
Complete legal description
SW¼,NE¼,NW¼,SW¼,Sec 30,T15N,R1W, SM, AK
Location (site address or directions)
18741 Monastery Drive, Eagle River,
Alaska 99577
Property owner
Mailing address
PrPd z ,~y~ Ar~Tidsnn Dayphone 696-2]60
18741 Monastery Drive, Eagle River, AK 99577
Lending agency
Maifi'ng address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: § z{ ,~
TYPE OF WATER SUPPLY:
NOTE:
Individual well ×
,. Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ×
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
.J
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the Validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein, I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Lawrence C. Lockyer
18739 Monastery Drive,
Address
Engineer's sig nat u re ~(_~j~'---"
bedrooms.
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
Phone 696-3437
Eagle River, AK 99577
Date 11/5/92
bedrooms, with the following stipulations:
Additional Comments
By: ./~'~.Z('j,4X.. ~,~'~'~,-r~-'-'-- Date //'~J"~.~/~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
724)25 (Rev 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegaIDescription: SW¼,NE¼,NW¼,SW¼,Sec 30,
T15N, R1W, SM,AK
Parcel I.D.
A. WELL DATA
Well type IndJv.
Log present (Y/N) Yes
· Totaldepth 400 ' *
Sanitary seal (Y/N) Ye s
· Per Well Log
Date of test
Static water level
Well flow
If A, B, or C, attach ADEC letter. ADEC water system number N/A
Sullivan
Date completed 6/27/84* Driller
Cased to. 13 ' 4"* Casing height
Wires properly protected (Y/N)
20"
FROM WELL LOG
Yes
AT INSPECTION ~ c~
9/7/92 ~
6/27/84
90'
25 9ph ~. ~.¥n.
Pump level ? 388 '
*Although yield is low, this is supplemented b'~ a 700 qal st ~c~:~ge tank
which J_s ~deouate to mee~ instantaneous cteraana for a ~our b~t~t~oom house.
SEPARATION DISTANCES FROM WELL TO: ~
Septic/holding tank on lot
Absorption field on lot
Public sewer main N/A
Sewer service line N/A
110'
100'+
100'+
; On adjacent lots
; On adjacent lots 100 ' +
Public sewer manhole/cleanout N/A
Petroleum tank N/A
WATER SAMPLE RESULTS:
Coliform Passed Nitrate
Date of sample: g-/-671r2- Nitrate
~~oliform
B. SEPTIC/HOLDING T.~NK DSA
Passed Other bacteria Passed
Collected by:
S&S Engineers
Dona Lockyer
Date installed 9/4/84* Tank size 1250' Compartments 2*
Cleanouts (Y/N) Yes Foundation cleanout (Y/N) Yes Depression (Y/N)
High water alarm (Y/N) N/A Alarm tested (Y/N) N/A
Date of pumping 8/13/9 2 Pumper JR ' s Pumping
No
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 110 '
To property line 100'+
Surface water/drainage
*Per As-Built
72-026 (Rev. 7/91) Front
On adjacent lots
Absorption field
N/A
100'+
Foundation 30 ' +
watermain/serviceline 100'+
CONTINUED ON BACK PAGE ·
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed 9/4/84*
Length 4 ? ' Width
Total absorption area 588 '
Depression over field (Y/N) Eo
Surface water
Soil rating 125 sf/bed System type Trench
3f~" Gravel thickness 7 ' Total depth 10 '
Cleanouts present (Y/N) Yes
Date of adequacy test 9/7/92
Results (pass/fail) t~ass for ¢ "/ bedrooms
Peroxide treatment (past 12 months) (Y/N) NO If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
'+
On adjacent lots 100 '+ Property line 80
To existing or abandoned system on lot
Cutbank [q/A Water main/service line 118 '+
Driveway, parking/vehicle storage area 30 ' +
Well on lot 118 '
To building foundation
On adjacent lots 100
Surface water N/A
Curtain drain N/A
60'+
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Engineer's Name
Date ~-
HAA Fee $ ,'~C~ Lb ,LbO
Bate of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
General Information
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALT~H AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
Application Date '~'c~-(~
(a)
(b)
Legal Description (include.lot, block, subdivision, section, township, range)
Location (address or directio.ns)
Telephone - Home
Bus ines s
(c) Applicant is (check one) Lending Institution ~ ; O~ner/builder ~j
Buyer ~; Other ~-~ (explai=); .-_
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
~Ma~-l~ the HAA to the following address:
~7pe of Residence
Single-Family~
Number of Bedrooms
Multi-Family
Other (describe)
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
S. ewa~e Disposal
Onsite~ Public ~ Community ~ Holding Tank ~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
En~ineerin$ Firm Prov~d~n~ Inspections~ Tests~ File 8earch~ Data and Information_
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein.. I further verify that,
based om the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regulaT
tions in effect on the date of this inspection.
(ENGINEER~r*~o/ m,~ ~- *"~ ~ ~.'~
Approved for bedrooms By Dar
'/ ~ '~nditioaal
Approved ~ DisapproVed ~ --~dltioaal
Terms of Conditio~al Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIROS~dENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEN~f-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY ~N INDEPENDENT PROFESSIONAL ENGII~ER REGISTERED
IN TMM STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. T~W. MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK°
(DHEP SEAL)
RR4/eO/DI8
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAAi
CHECKLIST - FEBRUARY 1984
Well Classification ~%q'~c~-~
Well Log P~esent ~/J~)
Total Depth ~//d~) t Cased to
Static Water Level ~O~-
Casing Height Above Ground
Elect~ica~ Wiring in Conduit ~/~)
Separation Distances f~om Well:
To Septic/Holding Tank on Lot
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MAR 2 9 g85
Legal Description,
If A, B, ~ C, D.E.C. ~p~o~d~)
~/~/~ Yield~ ~
~p~ of ~outing
Sanit~ ~al on ~sin~
~ession ~nd ~l~ead (~
Date Completed
Pump Set At
To Nearest Edge of Abso~13tion Field on Lot
; On Adjoining Lots ~//~
/~ ! ; On Adjoining Lots .~k~
To Nearest Public SeWe~ Line /-/.~- To Nearest Public Sewer
Cleanout/Map_hole ./4,Z'//~ TO Nearest Sewer Service Line on LOt
Water Sample Collected By-~$ ~(~.-~/~; Date ~-~b& --~'-~7'
Water Sample Test Results ~'~7~/_v ~/~ c ~ ~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~F--~--~ ~ Size /~zj~ No. of Compartments ~
Standpipes ~ Ai~-ti~t ~ps ~) Foun~tion Cleanout ~)
~ession o~ Ta~ ~ ~te. ~st P~d ~~
Holding Ta~ High-Wate~ ~a~ (Y~) ~ '~~ Holdi~ Ta~ ~t
~p~ation Distils ~ ~ptic~olding Ta~:
To Water-Supply Well
To Property Line
To Weter Main/Service Line ~/~
Course
Cor~aents
To Buildin9 Foundation
To Disposal Field
TO Staream, Pond, Lake, c~ Major D~ainage
Receipt $
Date Paid:
Amount: L~ XD('~
[Page 1 of 2] 2-15-84
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date .Installed ~-. Lf - ~ ~/
/~7/~-- Type of System Design
Length of Field Z~~
Width of Field
Square Feet of Absorption A~ea %~/~ ~
Depression over Field (~f~) Date of Last Adequacy. Test
Results of Last Adequ,acy Test ~/~ .
Separation Distance f~cm A~sorption Fi/eld:
Depth of Field /~ ~
Gravel Bed Thickness ~!
Standpipes P~esent ~/~)
To ~ater-Supply Well
To Building Foundation
Lot /%//~ ; On Adjo. ining
To Water Main/Service Line /~///~'
To Stream/Pond/Lake/or Major D~ainage Course
To D~iveway, Parking A~ea, or Vehicle Storage Area
Comments
To P~operty Line
To Existing or Abandoned System cn
Lots
To Cutbank(if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Weter Alarm Level at
Tested for
Electrical Codes(Y/N)
Cor~rents
Din~nsions /
. Manhole/Access ~/N )
"Pump ~f" Legist
/
Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request
certify that I have checked, verified, or conforr~d to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed
Company
KB1/d5/s
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2-15-84